4 QUIZ (True/ False) 1. Clostridium DifficileIs present in gut of one quarter of > 65 yr oldsLies dormant without causing symptomsMultiplies rapidly when normal gut flora disturbed, producing toxins causing illnessIs usually spread on the hands of health workerscan form spores which can survive for long periods in the environmentCan be eliminated from the hands by alcohol hand gelCan be controlled partly by reducing use of broad spectrum antibiotics

6 QUIZ: 3. Sore ThroatList 5 indications for admitting a patient with a sore throatTRUE OR FALSE:Throat swabs should be routinely takenAntibiotics prevent suppurative complicationsAntibiotics should be given to patients on immunosuppressive chemotherapyAntibiotics prevent the development of rheumatic fever and acute glomerulonephritis

7 QUIZ: 4. Sore Throat (cont)The following patients should usually be prescribed antibiotics for sore throat by the GP:Recurrent tonsillitisWith an increased risk of severe infection (e.g. diabetes or immunocompromised).Who are at risk of immunosuppression (e.g. on disease-modifying anti-rheumatic drugs [DMARDs], carbimazole).With a history of valvular heart disease.With a history of rheumatic fever.With peritonsillar abscess

8 5. OTITIS MEDIA True/False70% resolve within 3 days without antibioticsAnalgesics are the mainstay of treatmentFor most patients frequency of side effects of antibiotics are similar to frequency of benefitAntibiotics more likely to help the following groups:above 6 months of agesystemically unwellPurulent discharge

9 6. OTITIS MEDIA True/FalseIf a delayed prescription is offered, instructions should be to use if not improved after 48 hoursAmoxicillin for 7 days is first line if antibiotics are usedPreferred second line treatment (if recurrent) includes cefalosporinsTrimethoprim is also a second line option

10 7. Acute Sinusitis True/FalseReserve antibiotics for cases persisting more than 5 days in adults and 7 days in childrenPlain sinus x ray is useful in establishing a diagnosisIntranasal decongestants may have a short term benefit

11 8. Treatment Duration How Long should antibiotics be used for:Otitis MediaUncomplicated pneumoniaAcute SinusitisTonsillitisAcute exacerbation of COPDUncomplicated lower UTIComplicated UTIProstatitisEpididymo-orchitis

13 10. Pelvic Inflammatory DiseaseTRUE/ FALSEA chlamydial swab of the cervix and HVS should be taken prior to treatmentShould be treated before results of swabs if unwell, using broad spectrum combinationSpecify broad spectrum regime – name of antibiotics, dose, durations

14 11. Impetigo TRUE/ FALSE Topical therapy is preferredBactroban is preferred choice of topical therapiesShould be treated for 5 days if oral antibiotics are usedIs caused by staphylococcus aureus or streptococcus pyogenes

16 13. Dermatophyte infections - tinea capitisTRUE/ FALSEScalp scraping and hair root should be sent for fungal cultureTopical imidazole creams are ineffectiveShould be referred to a dermatologistOral Griseofulvin is recommended

17 14. Dermatophyte infections - tinea corporis/ cruris/ pedisTRUE/ FALSESkin scrapings should be routinely sent for fungal cultureTopical imidazole creams are effectiveShould all be referred to a dermatologistTopical treatments should be continued for 1-2 weeks after clinical cure

18 15. Dermatophyte infections: fungal nail infectionsTRUE/ FALSENail clippings should be routinely sent for fungal cultureTreat only positive nail clippingsShould not be treated if only symptoms are cosmetic appearanceFor toe nail infections treatment is usually needed for 3 months

19 16. Antivirals SHINGLES – TRUE/ FALSE Oral antiviral are indicated in:Healthy 50 year old man presenting within 24 hrs of appearance of rash on trunk24 year old with ophthalmic shingles rash for 48 hrs80 year old presenting with chest wall shingles after 96 hours

21 QUIZ (True/ False) 1. Clostridium DifficileIs present in gut of one quarter of > 65 yr olds FALSE (1/3 of over 65 yr olds)Lies dormant without causing symptoms TRUEMultiplies rapidly when normal gut flora disturbed, producing toxins causing illness TRUEIs usually spread on the hands of health workers TRUEcan form spores which can survive for long periods in the environment TRUECan be eliminated from the hands by alcohol hand gel FALSECan be controlled partly by reducing use of broad spectrum antibiotics TRUE

22 Consequences of high community prescribingMRSA: Staphylococcus aureus (SA) is a bacterium found on the skin of around 30% of the general population at any time causing no apparent ill effect. This is known as colonisation. SA infections of the skin may cause pimples or boils. However, inside the body, it can cause serious infections such as pneumonia, organ failure and death.MRSA (Methicillin-resistant SA) is a form of SA that is resistant to commonly used antibiotics. Individuals can be colonised with SA or MRSA and are carriers of the organisms, possibly passing them on to others through physical contact.Clostridium difficile (C.Diff):C.diff (Clostridium difficile) is a bacterium found in the gut of around a third of people aged 65 and over. It lies dormant causing no ill effect until the normal flora of the gut is disturbed (e.g. through taking antibiotics), when it can multiply and produce toxins. It then causes severe explosive diarrhoea. Spread may then occur via the hands of healthcare workers, or from contaminated objects or contaminated food. C.diff can form spores which can survive for long periods in the environment and be dispersed through the air.

26 QUIZ: 4. Sore Throat (cont)The following patients should usually be prescribed antibiotics for sore throat by the GP:Recurrent tonsillitis FALSEWith an increased risk of severe infection (e.g. diabetes or immunocompromised). TRUEWho are at risk of immunosuppression (e.g. on disease-modifying anti-rheumatic drugs [DMARDs], carbimazole). TRUEWith a history of valvular heart disease. TRUEWith a history of rheumatic fever. TRUEWith peritonsillar abscess FALSE (ADMIT)

27 5. OTITIS MEDIA True/False70% resolve within 3 days without antibiotics FALSE – (80%)Analgesics are the mainstay of treatment TRUEFor most patients frequency of side effects of antibiotics are similar to frequency of benefit TRUEAntibiotics more likely to help the following groups:above 6 months of age FALSEsystemically unwell TRUEPurulent discharge TRUE

28 6. OTITIS MEDIA True/FalseIf a delayed prescription is offered, instructions should be to use if not improved after 48 hours FALSE (72 hours)Amoxicillin for 7 days is first line if antibiotics are used FALSE (5 DAYS)Preferred second line treatment (if recurrent) includes cefalosporins FALSETrimethoprim is also a second line option FALSE – CO-AMOXICLAV/ ERYTHROMYCIN/ CLARITHROMYCIN

31 7. Acute Sinusitis True/FalseReserve antibiotics for cases persisting more than 5 days in adults and 7 days in children FALSE (7 days adults 10 days children)Plain sinus x ray is useful in establishing a diagnosis FALSEIntranasal decongestants may have a short term benefit TRUE

38 14. Dermatophyte infections - tinea corporis/ cruris/ pedisTRUE/ FALSESkin scrapings should be routinely sent for fungal culture TRUETopical imidazole creams are effective TRUEShould all be referred to a dermatologist FALSETopical treatments should be continued for 1-2 weeks after clinical cure TRUE

39 15. Dermatophyte infections: fungal nail infectionsTRUE/ FALSENail clippings should be routinely sent for fungal culture TRUETreat only positive nail clippings TRUEShould not be treated if only symptoms are cosmetic appearance TRUEFor toe nail infections treatment is usually needed for 3 months TRUE

40 16. Antivirals SHINGLES – TRUE/ FALSE Oral antiviral are indicated in:Healthy 50 year old man presenting within 24 hrs of appearance of rash on trunk FALSE24 year old with ophthalmic shingles rash for 48 hrs TRUE80 year old presenting with chest wall shingles after 96 hours FALSE

46 Care pathway for respiratory tract infections (RTIs)Address patients’ or parents’/carers’ concerns and expectations when agreeing the use of the three antibiotic strategies:no prescribingdelayed prescribingimmediate prescribing

47 No AntibioticsAgree a no antibiotic or delayed antibiotic prescribing strategy for patients with acute otitis media, acute sore throat/acute pharyngitis/acute tonsillitis, common cold, acute rhinosinusitis or acute cough/acute bronchitisNo antibiotic prescribing Offer patients:reassurance that antibiotics are not needed immediately because they will make little difference to symptoms and may have side effects, for example, diarrhoea, vomiting and rasha clinical review if the RTI worsens or becomes prolonged.

48 Delayed Antibiotics Delayed antibiotic prescribing Offer patients:reassurance that antibiotics are not needed immediately because they will make little difference to symptoms and may have side effects, for example, diarrhoea, vomiting and rashadvice about using the delayed prescription if symptoms do not settle or get significantly worseadvice about re-consulting if symptoms get significantly worse despite using the delayed prescription.The delayed prescription with instructions can either be given to the patient or collected at a later date

49 Immediate prescribingConsider an immediate prescribing strategy for:children younger than 2 years with bilateral acute otitis mediachildren with otorrhoea who have acute otitis mediapatients with acute sore throat/acute pharyngitis/acute tonsillitis when three or more Centor criteria are present:presence of tonsillar exudatetender anterior cervical lymphadenopathy or lymphadenitishistory of feveran absence of cough

50 Offer all patientsadvice about the usual natural history of the illness and average total illness length:– acute otitis media: 4 days– acute sore throat/acute pharyngitis/acute- tonsillitis: 1 weekcommon cold: 11/2 weeksacute rhinosinusitis: 21/2 weeksacute cough/acute bronchitis: 3 weeksadvice about managing symptoms including fever (particularly analgesics and antipyretics). For information about fever in children younger than 5 years, refer to ‘Feverish illness in children’